June 2013 Ask the Expert: Managing Stress and Anxiety

During the month of June, Living Beyond Breast Cancer experts Kauser Ahmed, PhD, and Ruth Steinman, MD, answered your questions about how to cope with the emotions that you may feel after a breast cancer diagnosis.

Question: Could you talk a little bit about the kinds of medications you find helpful for anxiety and depression?

Dr. Steinman: This is a pretty broad question and the answer is that it depends on many factors: the presenting problems and your history; what medications you are already taking and what those interactions might be with a given psychotropic medication; what your family history is and whether or not a family member has bipolar illness, for example, or if a family member has responded well to a certain medication; whether or not you have a current or past problem with substance abuse; whether or not there is co-existing pain and what kind of pain that is; as well as many other factors.

Question: I never realized that my inability to sleep at night could be related to depression...are sleep medicines the only way to relieve this?

Dr. Steinman: Sleep can be impaired by depression and by other factors like daytime napping; medications which can interfere with sleep, like steroids; sleep apnea; and restless leg syndrome. Correction of the underlying problem can often improve sleep. Exercise is very important in any effort to improve sleep. It improves the quality of sleep by enhancing the time spent in the deepest stages of sleep, so you sleep longer but also awaken more refreshed. Often when there is a lot to worry about, bedtime can be a time when those worries swirl around in your head and it can be difficult to fall asleep. Listening to mindfulness meditation/relaxation CDs at bedtime can help you turn off the worried thoughts and enable you to fall asleep.

Question: Why take antidepressants that make you tired if you still won't want to do any of your normal activities?

Dr. Steinman: When they work as they are supposed to, antidepressants help relieve the fatigue and motivation difficulties that depression can cause. Often my patients will tell me when the antidepressant they are taking takes effect that they feel such a sense of relief to be able to enjoy activities again and to not have to struggle to accomplish things during the day. When antidepressants are not a good fit, they can cause side effects or can fail to improve the depressive symptoms. In that case, we stop the antidepressant trial and try again.

Question: I was initially diagnosed in 2010 and had a second recurrence in late 2012. I feel that overall I have managed the anxiety and stress, but when I received my second diagnosis I found myself to be very angry. I even put away all my pink ribbon items because it made me angry when I looked at them. I feel that I have moved past this now, but is this a normal process to go through?

Dr. Steinman: Absolutely! Recurrence is often much more difficult to manage emotionally than initial diagnosis. I can’t tell you how many patients have told me that October and all that goes with the breast cancer awareness campaigns can incite irritation, sadness, anger, guilt and other emotions.

Question: How do you develop a non-cancer identity when you have people around you (family, friends, coworkers) who are always looking at you and treating you like you still have cancer? I'm a 2 1/2 year (and counting) BC Survivor and at one point I had to tell some of my loved ones to please stop giving me breast cancer-related gifts. I've really been struggling with trying to create a non-cancer identity.

Dr. Steinman: Families and friends are often out of sync with where their loved one is emotionally in the cancer experience. I often hear the opposite of what you are expressing – that family and friends have moved on and expect that because treatment has ended life has returned to the pre-cancer life they all wish for. My patients then feel a sense of isolation and even guilt that they are still grieving and trying to find comfort with their new life after cancer diagnosis and treatment. What you are saying, though, is that sometimes the ones you love handle you with kid gloves too long. I would let them know that you understand their worry and you appreciate the ease with which they took on the caregiver role. Now it is time to let go a little and catch up to you.

Question: What do you do if you have no real family support (i.e., no spouse/partner, parents or children) and your disease is Stage IV MBC?

Dr. Steinman: I have seen many people without family support get tremendous benefit from the cancer support organizations like LBBC and the programs they offer. In-person cancer support groups as well as virtual person-to-person support can be enormously valuable. The Young Survival Coalition is a wonderful organization for this as is the Cancer Support Community.

Question: I'm on tamoxifen. I've heard many antidepressants keep tamoxifen from working. What are some antidepressants that would be compatible with tamoxifen?

Dr. Ahmed: This is an important question and really worth consulting about with a knowledgeable psychiatrist who has worked with individuals using tamoxifen, because good options do exist. As a psychologist, I do not prescribe medication and would not be able to make specific recommendations.

Question: If you're continuing to struggle with what may be PTSD 18 months post-diagnosis, is medication the best therapy?

Dr. Ahmed: Without knowing what exactly constitutes PTSD in your situation, it is difficult to say how best to address it. There are both good therapy and medication modalities that can help with PTSD symptoms, and are sometimes used together. If you are concerned about symptoms of PTSD, seek out a referral to a mental health practitioner who has specialization in medical psychology or trauma and follow their guidance.

Question: How do you look at all that has changed in your body and mind without feeling so inadequate for the future that lies ahead? No estrogen, CIPN [chemotherapy-induced peripheral neuropathy], memory loss and fatigue can really take a toll on your coping skills.

Dr. Ahmed: The transition from treatment to healthy survivorhood is its own complex process, and often, the first point at which women have the chance to catch their breath and assess all the changes that have happened to their bodies and their lives. It can feel daunting to move forward. I’m sure you all have heard that this is a time not for “going back to normal” so much as creating your “new normal.” First, give yourself a pat on the back for all the challenges you have faced, and then give yourself time to move forward gently and with patience. It takes time to start to feel more like yourself, and also takes time to figure out what changes you will need to make to your coping strategies, schedule and expectations of yourself. There is nothing inadequate about you or your life, just different than it was before. This is an excellent time as well to seek some short-term therapy to help you navigate this process and/or to find support through others who are also new survivors.

Question: I am currently in treatment for metastatic breast cancer. My original diagnosis was in 1998 with a recurrence in 2003, and again in 2012. I use 0.5 mg of lorazepam (Ativan) to manage the anxiety, but I am not sure if using it too frequently causes more anxiety or if I am also feeling some sense of depression that the remainder of my life may now be filled with chemo. I don't want to be on any long-term medicine, which I believe antidepressants are. How do you tell the difference between anxiety and depression and what is best to get you through the rough patches?

Dr. Ahmed: It sounds like you have been through a lot in the past several years and have had to make adjustments each time to get your bearings. Congratulations on your successes so far! The good news is that you are among a growing number of women who are living with metastatic breast cancer and really learning to manage it like a chronic condition. This comes with challenges, including possibly needing to “grieve” the losses you have experienced (including life without any treatment) as well as preparing for the ongoing triggers that can lead to heightened anxiety – like scans, changes in treatment, etc. Joining a support group of others who are charting a similar life course can be helpful. If feelings of anxiety or worry are not just transient, but seem to persist and begin to cloud how you feel most of the time, or affect your ability to live your life fully, then it is time to seek professional support.

Question: It's been 4 years since my DX of breast cancer. I had a very rough time with treatment, had a great support team and husband. Lately I just feel very angry about everything and nothing at all. I would say my main feelings are that I'm not where I thought I would be physically (in terms of recovery) by now. I just can’t figure out why I'm so angry all the time.

Dr. Ahmed: I’m sorry to hear that you’ve been having a rough time lately. Survivorship can be challenging for everyone, but it can be even more emotionally draining and difficult, and yes, can generate feelings of anger and irritability when ongoing late effects from the treatment linger even years after. Having a supportive partner and family/friends might even leave you feeling guilty and resentful that this experience is still keeping you from being where you want to be in your life. I would recommend that you seek out a survivorship consult if available in your area and, if not, then ask your oncologist to sit down with you to go over all of the symptoms you are having to see if there are appropriate referrals he or she can make for experts who can help you better manage those symptoms. Simply feeling as if you are doing something can help. I also suggest that you consider meeting with a therapist who can help you to have a safe space to talk through all that you’ve been feeling, which may include other concerns you have been feeling frustrated or sad about. Talking it all out may make all the difference, too. Good luck!

Question: I seem to be having a hard time emotionally with this cancer business. I had a mastectomy in January of 2012 and feel quite well physically. Is it possible that it takes this long to deal with the emotional aspect of breast cancer? I do feel guilty about talking about it, as most of my family thinks I should just move on.

Dr. Ahmed: If you talk with other survivors, you will hear that it is not at all uncommon for the emotional aspects of dealing with a breast cancer diagnosis to surface after the treatment is done. And many others, too, feel guilty about talking with their loved ones, thinking that they just want everything to be back to normal. This is often a time when survivors can suddenly feel out of sync with the people they care about the most. A support group for survivors, either in person or online if one is not available in your area, can really help you connect with other women who are beginning to grapple with the same questions and feelings that you are. And don’t assume that there is no one in your life who might be able to engage in these conversations with you. Try and think of one or two people who you think might be most receptive (a friend or family member who is especially understanding and patient), and ask if they are available to talk with you about the things you are feeling. You might be pleasantly surprised.

Question: How do you tell if the sadness and anxiety you feel are normal or clinical depression?

Dr. Ahmed: Some experiences of sadness and anxiety can be normal in the cancer experience or they can signal that professional help is needed to manage clinical symptoms of depression. Persisting symptoms (occurring more days than not, for 2 weeks or more) such as weepiness/low mood; feeling unworthy; significant changes in appetite, sleep, and concentration; as well as physical symptoms such as racing heart, agitation or having anxious/worried thoughts that don’t seem to go away, are cause for concern. Certainly any thoughts that your life isn’t worth living or that loved ones would be better off without you are an indication that you should seek help at once. Ultimately, if someone’s sadness and anxiety is getting in the way of functioning well in their life, it is worth seeking an evaluation for clinical depression/anxiety and taking the steps needed to get back on track. In going through cancer treatment, there are so many elements that can lead to the biophysical changes that bring on depression, sometimes for the first time in someone’s life. Being well fully is the goal and treating depression as you would any other major symptom is highly recommended.

Question: I noticed that I have so much more anxiety, restlessness and depression since I've been on Arimidex, which I started in December of 2012. I have been on Buspar for anxiety since July of 2012 (before dx w/ BC) due to some personal and family problems that just taking Xanax wasn't enough to control. My primary care physician put me on twice-daily Buspar, which was helping until the last couple of months. I have been on Arimidex for 6 months now. My anxiety and anger have gotten so bad that I started seeing a therapist in May, which isn't helping much. I can't get in to see a psychiatrist for 4 months and my husband is really concerned about my unpredictable moods and feelings of sadness, restlessness, anger and anxiety. Fortunately he is very patient with me. I assume it's the Arimidex that is making me feel this way. Is there something else, besides the Arimidex, I can take to help with the anxiety? I can't live like this with these mood changes for the next 5 years.

Dr. Ahmed: Endocrine therapies can sometimes contribute to mood changes, and it is definitely worth discussing with your oncologist the changes that you have noticed since beginning this medication so that together you can track its impact. Four months to wait to see a psychiatrist seems like a very long time; again, perhaps your oncologist can assist you by calling on your behalf to see if he or she can get you an appointment sooner. In the meantime, try adding some mindfulness meditation or breathing skills to your personal coping repertoire, as well as using exercise or yoga to help you manage the symptoms you are having. Since you are seeing a therapist, ask that he/she assist you with some specific cognitive behavioral strategies to help with these issues. Hopefully, using all these tools and modalities, things can get better for you soon.

Dr. Ahmed is a clinical psychologist at the Simms/Mann UCLA Center of Integrative Oncology in Los Angeles, Calif. She provides individual, couples and family counseling to patients and families coping with the impact of cancer in their lives as well as consultation to medical teams who treat individuals with cancer. She works closely with women undergoing treatment for breast cancer through the UCLA Revlon Breast Center and as co-facilitator of a weekly support group for women undergoing treatment for early diagnosis breast cancer.